Provider Demographics
NPI:1538274311
Name:4977, LLC
Entity type:Organization
Organization Name:4977, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:THIRD PARTY ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:FIGUEROA RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-521-8439
Mailing Address - Street 1:1000 N PEARL ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08302-1215
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 N PEARL ST
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:NJ
Practice Address - Zip Code:08302-1215
Practice Address - Country:US
Practice Address - Phone:856-453-5993
Practice Address - Fax:856-453-8631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
NJRS005859333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3142217OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NJ8611602Medicaid
NJ8611602Medicaid